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RBF CoP
Workshop
White Sands Hotel
Dar es Salaam
24th November 2015
Zanzibar Model: Key Goals of PBF
Primary Goals
1. Improve Quality of Services
2. Increase Utilization of Services
Secondar...
Zanzibar Model: Processes
Allocation
- by facility staff
- by MoH
Quarterly Performance Pay
Health Facility Performance
Fa...
Zanzibar Model: Why a quality focus?
Baseline facility performance
• Already relatively high OPD utilization: Average 1
vi...
Quality Components
IPC checklistDirect quality indicators
attached to fee for service
Community Verifcation The 'Quality T...
Curative indicators
Quantitative Qualitative Criteria
OPD- >5 years (new cases) – No payment According to Standard Treatme...
Components: Preventative indicators
Quantitative Qualitative Criteria
Children immunized against Penta 3 According to EPI ...
Results: Outpatients treated according to
guidelines (first year of implementation)
Results: IMCI guidelines adhered to
Impact on Health Outcomes/Child Mortality
• If treating children under 5 using IMCI guidelines reduces morbidity
and morta...
Unneeded antibiotic use in under 5s
207
330 260
441
526
553 784
48
0
200
400
600
800
1000
1200
1400
1600
1800
2000
Non PBF...
Rational antibiotic use – potential impact on
Zanzibar
• Cost of antibiotics prescribed but not required (estimated saving...
Number of clients/patients served in intervention and Control PHCUs and its change
between two period
Intervention PHCUs C...
Possible reasons for reduction in OPD
attendance
Patients sought for treatment in
facilities where antibiotics were freely...
Improved adherence to
guidelines leads to improved
health outcomes
The Zanzibar PBF model improves
health worker adherence...
Thank you for
your attention
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PbF in Zanzibar : Does the use of Quality Indicators result in sustainable improvement in health outcomes ?

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Omar Abdalla

Publié dans : Santé & Médecine
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PbF in Zanzibar : Does the use of Quality Indicators result in sustainable improvement in health outcomes ?

  1. 1. RBF CoP Workshop White Sands Hotel Dar es Salaam 24th November 2015
  2. 2. Zanzibar Model: Key Goals of PBF Primary Goals 1. Improve Quality of Services 2. Increase Utilization of Services Secondary Goals 1. More Efficient Resource Usage • Rational Prescription of Drugs • Demand-driven inputs purchase 2. Improve Staff Retention 3. Strengthen community involvement in improving service delivery  Facilitate the achievement of SDGs/improved Health Outcomes
  3. 3. Zanzibar Model: Processes Allocation - by facility staff - by MoH Quarterly Performance Pay Health Facility Performance Facility Staff Bonuses Community Facility Account Performance Pay Measuring Performance Legend: Facility & Community Verification PBF Indicators & Quality Assessment NB. Not all aspects of reform have been implemented yet. 30 Primary Health Care Facilities On Unguja and Pemba (2 Districts) Population xxx,xxx
  4. 4. Zanzibar Model: Why a quality focus? Baseline facility performance • Already relatively high OPD utilization: Average 1 visit per capita per year (adults and children combined) overall and 2.1 under 5, 2012 (Global target is 1 visit per capita per year and 2.3 visits per child <5 per year) But…. • Low service quality: Average of <25% patients treated according to guidelines (at baseline in pilot districts). Infection Prevention Measures were no in place.
  5. 5. Quality Components IPC checklistDirect quality indicators attached to fee for service Community Verifcation The 'Quality Tools'.
  6. 6. Curative indicators Quantitative Qualitative Criteria OPD- >5 years (new cases) – No payment According to Standard Treatment Guidelines OPD- <5 years (new cases) – No payment According to IMCI OPD (STI, Hypertension, Diabetes, Epilepsy) According to Guidelines Minor Surgery Adjusted for Infection prevention and control measures in place Patients with three cardinal TB symptoms referred/tested for AFB Facility Delivery Partogram completed as per guidelines and Adjusted for Infection prevention and control measures in place
  7. 7. Components: Preventative indicators Quantitative Qualitative Criteria Children immunized against Penta 3 According to EPI guidelines Children 6 monthly de-worming treatment Vitamin A Antenatal Visit (no payment) Four visits spaced with 4-6 week intervals according to FANC Antenatal Visit (no payment) First Visit within 16 weeks Postnatal care Within 48 hours according to guidelines New Family Planning Consultation Family Planning-Implant Adjusted for Infection prevention and control measures in place Voluntary counselling & test for HIV ( PITC, DCT ) PMTCT: HIV+ mothers and children treated acc protocol Tetanus vaccination of girls 12yrs and above in schools
  8. 8. Results: Outpatients treated according to guidelines (first year of implementation)
  9. 9. Results: IMCI guidelines adhered to
  10. 10. Impact on Health Outcomes/Child Mortality • If treating children under 5 using IMCI guidelines reduces morbidity and mortality then PBF will improve health outcomes for 60% children in the PBF districts • If zinc treatment for children under 5 following an episode of diarrhoea reduces mortality and morbidity then PBF will improve health outcomes in about 20% of the children in the PBF Districts
  11. 11. Unneeded antibiotic use in under 5s 207 330 260 441 526 553 784 48 0 200 400 600 800 1000 1200 1400 1600 1800 2000 Non PBF 2013 Non PBF 2014 Pre PBF 2013 PBF 2014 <5 <5 <5 <5 with antibiotics Unneccessary antibiotics without antibiotics Saving of TZ16.5m per year (2 districts/ (antibiotic s only)
  12. 12. Rational antibiotic use – potential impact on Zanzibar • Cost of antibiotics prescribed but not required (estimated saving of TZS 22million per year in the two PBF Districts) • Increased number of antibiotics shared, uncontrolled, in the community • Antibiotic resistance • Increased resistance in individuals • Increased antibiotic resistance to low cost, first line antibiotics in the population
  13. 13. Number of clients/patients served in intervention and Control PHCUs and its change between two period Intervention PHCUs Control PHCUs Indicator April- June 2013 April- June 2014 Change April- June 2013 April- June 2014 Change DID Number of children immunized (Penta 3) 1147 1306 159 1112 1160 48 111 Number of pregnant women attended ANC first visit within 16 week 621 907 286 516 472 -44 330 Number of institutional delivery 394 519 125 387 398 11 114 Number of OPD cases 39280 38118 -1162 39657 41870 2213 -3375 Number of OPD cases adhered with guidelines 9784 31802 22018 15281 13884 -1397 23415
  14. 14. Possible reasons for reduction in OPD attendance Patients sought for treatment in facilities where antibiotics were freely prescribed, even for minor ailments. Reduced health seeking in people in need of treatment. Reduced health seeking in people in need of treatment. Reduction of patients with minor ailments
  15. 15. Improved adherence to guidelines leads to improved health outcomes The Zanzibar PBF model improves health worker adherence to treatment guidelines and reduces prescription of unnecessary drugs (antibiotics) However…stagnation of curative out patients in PBF Districts compared with others requires further investigation
  16. 16. Thank you for your attention

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